Lazzeri Chiara, Bonizzoli Manuela, Cianchi Giovanni, Batacchi Stefano, Guetti Cristiana, Cozzolino Morena, Bernardo Pasquale, Peris Adriano
Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
Heart Lung Circ. 2018 Dec;27(12):1483-1488. doi: 10.1016/j.hlc.2017.10.011. Epub 2017 Oct 31.
Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients.
We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation.
In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups.
In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support.
急性呼吸窘迫综合征（ARDS）已被证明常与需要使用血管升压药的血流动力学不稳定相关。迄今为止，在血流动力学不稳定的ARDS患者中使用静脉-静脉体外膜肺氧合（VV-ECMO）仍存在一些不确定性。
因此，我们评估了接受ECMO前血管升压药治疗的患者预后是否更差，此外，我们回顾了92例接受VV-ECMO治疗的难治性ARDS连续患者中与使用ECMO前血管升压药相关的因素。所有患者在植入前均接受了超声心动图检查。
在我们的系列研究中，55例患者（59.7%）接受了血管升压药治疗。感染性休克是需要血管升压药的主要原因（45.5%）。与未使用血管升压药的患者相比，使用血管升压药的亚组序贯器官衰竭评估（SOFA）评分显著更高（p=0.040），pH值更低（p=0.013），pO2值更低（p=0.030），乳酸水平更高（p=0.024）。在使用血管升压药的患者中观察到右心室（RV）功能障碍和双心室功能障碍的发生率更高（分别为p=0.018和p=0.036）。重症监护病房（ICU）死亡率为43.4%（40/92），两个亚组之间无差异。
在需要VV-ECMO的难治性ARDS中，很大一部分患者需要输注血管升压药，与血流动力学稳定的患者相比，这些患者的预后并未更差。ECMO前超声心动图有助于对这些患者进行特征描述，因为他们显示出RV（和双心室）功能障碍的发生率更高。根据我们的数据，在对传统治疗难治的ARDS患者中，血流动力学不稳定不应被视为VV-ECMO支持的禁忌证。
